Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heights Rehabilitation And Healthcare Center, The during CMS and state inspections, most recent first.
Delayed CPR Initiation for a Full Code Resident: A resident with a Full Code order was found unresponsive, not breathing, and without vital signs, but CPR was not started immediately. RN staff contacted the ADON after first attempting to reach the on-call NP, and EMS later arrived to find CPR not in progress, with the resident only being ventilated by BVM. EMS re-started CPR, but resuscitation was unsuccessful and the resident was pronounced deceased.
Failure to Provide Ordered Care and Timely Treatment: The facility did not ensure ordered wound care, PEG tube site cleansing, PRN respiratory treatment, or incontinence care were completed as documented. One resident had missing or delayed ACE wrap orders for bilateral leg wounds, another had a skin tear dressing left in place with unclear treatment completion, a resident with a PEG tube had a soiled, foul-smelling site with missed cleansing documentation, and an incontinent resident was found saturated with urine and wearing two briefs. The facility also failed to give an ordered PRN breathing treatment before a resident with COPD and respiratory distress was transferred to the ER, and did not provide timely care during a change in condition when another resident became tachypneic and tachycardic.
Double Portion Meal Orders Not Met: The facility failed to serve lunch trays in accordance with ordered double portions for multiple residents with conditions including DM, ESRD on dialysis, CKD, malnutrition, dementia, and obesity. Surveyors observed the tray line serving only 15 raviolis to residents ordered double portions, while the regular portion was 10 raviolis and the large portion was 12. The Dietary Manager and RD confirmed the servings did not equal twice the regular portion, and the Administrator stated there was no diet formulary defining diet parameters.
Incomplete and inaccurate resident record documentation: Multiple resident charts lacked complete documentation of transfers, outcomes after ER/hospital send-outs, and medication/treatment administration. One resident’s TPN was charted as “see progress notes” without the RN who started it signing off, several residents’ records did not show what happened after transfer, and one ventilator-dependent resident’s code event was documented with incorrect times and notification details. The DON confirmed the charting errors and missing documentation.
Bathing facilities were not maintained in proper working order. An observation found a shower room closed until further notice, and staff including an LPN, DON, ADON, Administrator, and Regional Maintenance Director confirmed the room with the only tub had been out of order for an extended period and was not being repaired. A separate shower room also had displaced tiles and a hole in the wall, which an LPN verified.
A resident with COPD, chronic respiratory failure, diabetes, CKD, dementia, a G-tube, and multiple wounds developed a change in condition with congestion, decreased lung sounds, fever, low BP, and abnormal labs. When the resident was transferred to the ER for septic arthritis, osteomyelitis, aspiration pneumonia, and a UTI, there was no documentation that the nurse called report or sent the associated lab results, and the ER MD documented that no report was received.
Failure to Provide Required ADL Grooming and Bathing Care: Two dependent residents did not receive needed ADL assistance. One resident with multiple chronic conditions and intact cognition had overgrown facial hair and requested shaving, while another resident with dysphagia, a trach, and a feeding tube had no documented bathing for months and was observed with greasy, matted hair and crusted debris; staff were unsure when the resident last received a shower or bed bath.
A resident with multiple chronic conditions, including dementia and diabetes, developed a left heel DTI that was monitored by the ADON and WNP. The wound was documented as enlarging over time, and the ordered treatment included cleansing with NS, applying skin prep, covering with ABD gauze, loosely wrapping with kerlix, and using offloading boots. During observation, the boots were not properly attached to the heel, and the dressing lacked the ordered ABD layer under the kerlix, which the ADON confirmed.
Significant Medication Errors for Antihypertensive and IV Antibiotic Therapy: Two residents were affected by missed or delayed medications. One resident with HTN, MS, and impaired cognition had headache, confusion, and very high BP, but ordered Losartan was not given until the next morning after hospice ordered it. Another resident with multiple serious diagnoses missed several doses of ordered IV antibiotics and an antifungal (Daptomycin, Meropenem, and Mycamine), and the MAR and nursing notes did not document a reason for the omissions.
Unattended medications were found at a resident’s bedside while the resident was sleeping. The resident had diabetes, chronic pain, depression, anxiety, and HTN, and was dependent for toileting, bathing, and personal hygiene. An RN could not identify the tablets and capsule in the medication cup and stated the resident had not yet received the meds, noting they may have been left from the evening shift. The resident was unaware the cup was there.
Ordered HgA1C Labs Not Completed Quarterly. A resident with multiple chronic conditions, including DM2 with neuropathy, had an order for quarterly HgA1C labs, but there was no evidence the March lab was completed. The resident stated she had not had recent lab work, and an RN ADON confirmed the A1C levels were not checked as ordered; the original lab order was later discontinued and reordered.
Infection control standards were not followed for a resident on contact isolation and another resident receiving wound care. An RN entered a room without gown or gloves, handled an enteral feeding tube, and left without hand hygiene, while CNAs also entered without PPE and believed the isolation had been discontinued even though active MDRO contact precautions remained ordered. In a separate event, an RN performed heel wound care using unclean scissors from her pocket, placed supplies on the resident’s bed, and did not change gloves or perform hand hygiene between cleansing the wound and applying the new dressing.
Failure to administer a consented influenza vaccine occurred for a resident with COPD, morbid obesity, anxiety, and tracheostomy status. The resident signed the vaccine consent form, but the EMR immunization record showed no data available, and the DON confirmed the resident did not receive the flu vaccine after consenting. The facility policy stated residents without contraindications would be offered the influenza vaccine annually and that administration details would be documented in the medical record.
A Business Office Manager misappropriated resident funds by writing checks to herself, making unauthorized purchases, and failing to follow required procedures for resident fund management. Multiple residents, including those with cognitive impairments and legal guardians, were affected, with items purchased that were not authorized or never received. Staff observed irregularities but did not escalate concerns, and families confirmed they had not approved many of the transactions.
A resident with complex behavioral health and pain management needs did not receive scheduled medications in a timely manner after requesting them during the night. The assigned RN, citing concerns about the resident's agitated behavior, did not administer the medications or seek assistance from other available nurses, resulting in a delay of care and unmanaged pain. Facility policies and individualized care plans were not followed, as confirmed by staff interviews and documentation review.
A resident with PTSD did not have an individualized care plan addressing her specific triggers, such as discomfort with people entering her personal space. Staff were unaware of these triggers until informed by the resident, and no formal interventions or documentation were in place to minimize the risk of re-traumatization.
A resident dependent on staff for all ADLs was found with visibly soiled bedding that was not changed promptly, with a dried brown stain near the wrist area believed to be blood from a recent blood draw. Additionally, a CNA and surveyor observed a large hole with broken tiles in the south wing shower room wall, which had the potential to affect multiple residents using that area.
Two residents with complex medical needs experienced uncomfortably high room temperatures due to malfunctioning air conditioning units. Staff and family members reported that the rooms were hot, with one room measured at over 81 degrees Fahrenheit and both rooms requiring the use of fans and wet blankets. Maintenance and nursing staff were not fully aware of the extent of the issues, and temperature logs were not up to date, resulting in a failure to provide a safe and comfortable environment as required by facility policy.
A facility failed to comprehensively assess and monitor a resident's bruises following a fall. The resident, with a history of cerebral infarction and aphasia, was admitted without skin impairments but developed bruising after a fall. Although monitoring orders were in place, documentation lacked detailed descriptions and progression of the bruises, leading to a deficiency finding.
A resident's medical records were improperly disclosed to an unauthorized family member due to a miscommunication during a care conference. The facility's policy on maintaining the privacy of health information was violated, affecting one resident with severe cognitive impairment.
The facility failed to report and investigate an alleged abuse incident involving a resident with severe cognitive impairment. The resident called the police, claiming staff beat her, but no documentation or investigation followed. The facility's abuse prevention policy requires prompt investigation and reporting of such allegations.
Delayed CPR Initiation for Full Code Resident
Penalty
Summary
The facility failed to timely provide basic life support, including CPR, to a resident with a Full Code advance directive after the resident was found unresponsive, not breathing, and without vital signs. The resident had multiple serious diagnoses, including end stage renal disease, COPD, cirrhosis of the liver, and CHF, and the record showed the resident was cognitively intact and had an active Full Code order. When the resident was discovered during early morning rounds, RN #439 noted the resident was unresponsive, had no vital signs, fixed and dilated pupils, mottled skin, and a cold, stiff body with a sunken appearance. RN #439 contacted another RN, then attempted to reach the on-call NP without success and notified ADON #419 that the resident was unresponsive and absent of vital signs. ADON #419 instructed the nurses to begin CPR because the resident was Full Code. The record and interviews show there was a delay before CPR was started, and the linked documentation conflicted on the exact start time. EMS arrived at the facility and found CPR was not in progress; the resident was being ventilated by BVM only. EMS personnel asked why CPR had stopped, and a staff member stated, "because you guys walked in and my back hurts." EMS then re-initiated CPR and continued resuscitative efforts. The EMS report stated the resident was last seen well approximately two hours earlier and was pronounced deceased after unsuccessful resuscitation. Interviews with RN #439, RN #301, ADON #419, the DON, and EMS personnel confirmed that the resident was Full Code, that CPR should have been started immediately, and that CPR was not being continuously performed when EMS arrived. Facility policy stated CPR should be initiated immediately when cardiac or respiratory arrest occurs and discontinued only by physician order and/or arrival of rescue personnel.
Failure to Provide Ordered Wound, Tube Site, Incontinence, and Change-in-Condition Care
Penalty
Summary
The facility failed to ensure wound care orders were updated and treatments were administered as ordered for multiple residents. For one resident with a history that included cerebral infarction, pyogenic arthritis, diabetes, end stage renal disease, and vascular wounds, wound care notes documented orders for lightly wrapping both lower extremities with ACE wraps every morning and removing them at bedtime, but there was no documented evidence of the order until later in the record. An observation showed the resident in her room without ACE wraps in place, and the wound practitioner confirmed the order had first been written earlier than it appeared in the physician order record. The assistant director of nursing confirmed the ACE wrap order had not been added until the day before the interview. For another resident admitted with a left femur fracture, muscle weakness, and difficulty walking, the admission assessment identified a skin tear to the left arm. The physician ordered daily cleansing of the skin tear with normal saline, application of calcium alginate, and coverage with a silicone foam dressing. The treatment record showed the dressing care was documented only on two days in May, and an observation later showed the resident still had a silicone foam bandage dated several days earlier. The LPN who observed the dressing stated she was unsure of the dressing orders. The facility also failed to provide ordered care for a resident with a gastrostomy tube and for a resident with incontinence. For the resident with the PEG tube, the order was to cleanse the tube site with normal saline every day shift, but the treatment record showed missed documentation on multiple days. Observations found the tube site covered with an undated gauze dressing, a large amount of dried dark debris, and a foul pungent odor, and the resident’s wife reported the site had rarely been cleaned. For the incontinent resident, observation showed two incontinence briefs in place, saturation with urine through both briefs and onto the mattress, and a strong odor of stale urine. The CNA present stated residents should not wear more than one incontinence product and was unaware when the resident had last received incontinence care. The facility also failed to provide ordered PRN breathing treatment for a resident with COPD, chronic respiratory failure, diabetes, CKD, vascular dementia, and a gastrostomy tube when the resident developed tachypnea and tachycardia and was transferred to the ER; the MAR showed the breathing treatment was not administered at any time in March. In addition, for a resident with dementia, anxiety, and wandering, the facility did not provide timely and appropriate care during a change in condition when the resident was tachypneic, tachycardic, and had crackles noted in the lungs before transfer to the ER.
Double Portion Meal Orders Not Met
Penalty
Summary
The facility failed to serve meals that met the nutritional needs of residents who were ordered double portions at lunch. Record review identified 24 residents with orders for double entree, double protein, or double portion meals, including residents with diagnoses such as diabetes mellitus, end stage renal disease on dialysis, severe protein calorie malnutrition, chronic kidney disease, morbid obesity, dementia, depression, and other chronic conditions. Their records and dietary assessments documented that they were supposed to receive increased meal portions as part of their diet orders and nutritional care plans. During observation of the lunch meal tray line on 05/19/26, surveyors observed [NAME] #405 using a #16 scoop to serve cheese ravioli and counting portions to ensure residents received 10 raviolis. Residents with orders for double portions were served 15 raviolis. At the time of observation, [NAME] #405 stated the production sheet indicated a #16 scoop was to be used for ravioli and that a portion size was 10 raviolis. [NAME] #405 confirmed that residents with double portion orders received 15 raviolis. Review of the production sheet with the Dietary Manager showed the #16 scoop was intended for the sauce on top of the ravioli, the regular portion was 10 raviolis, and the large portion was 12 raviolis. The Administrator stated the facility did not have a diet formulary defining what each diet meant or the parameters for each diet. The Registered Dietitian confirmed that double portions meant residents should receive twice the regular portion, not the large portion listed on the production sheets or the one-and-a-half portions that were served at lunch.
Incomplete and inaccurate resident record documentation
Penalty
Summary
The facility failed to accurately document resident care and outcomes in multiple medical records. Review of records, interviews, and the facility’s charting policy showed that the clinical record was expected to be accurate, legible, and complete, including documentation of admission, transfer, discharge, and follow-up actions. The deficiency affected five residents in the sample reviewed, including residents whose records did not show what happened after transfer to the hospital or emergency room, and one resident whose code event was documented with incorrect times and notification details. For one resident with hemiplegia and hemiparesis after stroke, diabetes, a gastrostomy tube, atrial fibrillation, and other diagnoses, an RN documented a change in condition with fixed gaze, stiffness, abnormal vital signs, and transfer to the ER, but the record did not show whether the resident was admitted, transferred elsewhere, or returned to the facility. For another resident with postsurgical malabsorption, chronic kidney disease, and depression, the MAR repeatedly showed TPN as “other/see progress notes,” while progress notes stated an LPN documented that the TPN was administered by whichever RN was scheduled, and the RN who started the infusion did not sign off that it was started. The DON stated the RN who administered the TPN should have documented it. A third resident with COPD, chronic respiratory failure with hypoxia, diabetes, dementia, a gastrostomy tube, and wounds had a change in condition with tachypnea, tachycardia, crackles, elevated blood sugar, and transfer to the ER after the NP was notified, but the chart did not document what occurred after transfer. A fourth resident with acute and chronic respiratory failure, morbid obesity, a peritoneal abscess, diverticulitis with perforation and abscess, CKD, hypothyroidism, lymphedema, and a colostomy had low blood pressure and chills during therapy, requested ER transfer, and was sent out, but no further outcome was documented. For the fifth resident, who was ventilator-dependent and on dialysis, respiratory therapy documented a vent alarm, bucking the vent, no pulse, CPR, return of pulse, and transport to the hospital, while the nursing note recorded the event and notifications at incorrect times and with discrepancies; the DON confirmed the times and notifications were inaccurately documented.
Bathing Facilities Left Out of Service and Shower Room Damaged
Penalty
Summary
The facility failed to maintain resident bathing facilities in proper functioning order. On 05/17/26, an observation of the shower room by room [ROOM NUMBER] showed a sign on the door stating the shower room was closed until further notice, with no date on the sign. At that time, an LPN confirmed the shower room was out of order and had been for about one year. Later observations and interviews on 05/20/26 showed the shower room by room [ROOM NUMBER] contained a walk-in tub in the middle of the room, and the Regional Maintenance Director stated it needed repairs and was not going to be fixed because the census was low. The DON stated the shower room had been out of order since she began working at the facility over one year ago and confirmed it was the only shower room in the facility with a tub. The DON also stated it had been non-functional since the current owner took over the facility, and the Administrator confirmed it had been out of order for a while. On 05/26/26, the ADON stated she had worked at the facility for 10 years and the shower room containing the tub had been out of order the entire time. She added that in those 10 years, she only saw the tub used one time to bathe a dying resident whose last request was to receive a tub bath. In a separate observation on 05/17/26, the shower room by room [ROOM NUMBER] had displaced tiles at the bottom of the shower and a hole extending into the wall below the shower head. An LPN verified the displaced tiles and hole in the wall. This deficiency was investigated under Complaint Number 2746747.
Failure to Communicate Resident Change in Condition and Lab Results During ER Transfer
Penalty
Summary
The facility failed to ensure nursing staff called report and sent associated laboratory reports to the ER when a resident had a change in condition and was transferred. Resident #120 had multiple diagnoses including COPD, chronic respiratory failure with hypoxia, diabetes, chronic kidney disease, high blood pressure, vascular dementia, prostate cancer, a cerebral aneurysm, a gastrostomy tube, and neuromuscular dysfunction of the bladder. The resident also had an order for the head of the bed to be elevated at least 30 degrees, received 5 liters of oxygen continuously, had an order for Ipratropium-Albuterol breathing treatments as needed, and had several wounds requiring daily dressing changes. The resident developed congestion, decreased lung sounds, fever, low blood pressure, and bradycardia, and the physician was notified with orders for labs, a urinalysis, and a chest x-ray. Lab work later showed a high WBC count and critically low hemoglobin and hematocrit, and additional lab work was ordered after the results were reported to the NP. When the resident was transferred to the ER for septic arthritis of the left hip, osteomyelitis in the sacral wound, aspiration pneumonia, and a UTI, there was no documentation that the nurse called report to the ER or sent the lab results. The ER record stated the resident was sent from the nursing home because of abnormal labs, but the specific abnormal labs were not provided by the facility, and the ER physician documented that no report from the nursing home was received.
Failure to Provide Required ADL Grooming and Bathing Care
Penalty
Summary
The facility failed to provide required ADL care for two dependent residents by not ensuring grooming and bathing needs were met. One resident, admitted with diagnoses including encephalopathy, spastic hemiplegia, type II diabetes with neuropathy, dysphagia, major depressive disorder, anxiety, schizoaffective disorder, legal blindness, obstructive sleep apnea, cerebral palsy, hypertension, diastolic heart failure, mild intellectual disabilities, and anemia, was assessed as cognitively intact and dependent on staff for toileting, showering/bathing, and personal hygiene. During observation, the resident had overgrown chin hair on her face and stated she wanted it shaved; the ADON confirmed a CNA would shave her. The resident’s care plan included assistance with ADLs such as dressing, grooming, personal hygiene, locomotion, and oral care as needed. Another resident, admitted with dysphagia, tracheostomy, and gastrostomy, was documented as dependent on staff for bathing and personal hygiene and incontinent of bowel and bladder. Review of the medical record for April and May showed no documented evidence of bathing. During observations, the resident was found in bed with greasy, matted hair and multiple large areas of crusted white debris, and both an LPN and a CNA confirmed the appearance and were unsure when the resident had last received a shower or bed bath. A later interview with an RN stated staff had assisted with giving the resident a shower, and the resident’s hair was then observed to be clean and unmatted.
Wound Care Not Completed Per Orders for Heel DTI
Penalty
Summary
Failure to provide pressure ulcer care per physician orders occurred for Resident #100, who was admitted with diagnoses including Alzheimer's disease, type 2 diabetes, repeated falls, dementia, anxiety disorder, major depressive disorder, hyperlipidemia, disorientation, delusional disorder, essential hypertension, and hypothyroidism. A skin inspection assessment documented no new skin issues, but a wound evaluation completed by the ADON identified a new pressure deep tissue injury on the resident's left heel measuring 5.5 cm by 6 cm. Subsequent wound care notes by the WNP documented the wound as larger, measuring 9 cm by 7.6 cm and later 9.5 cm by 6.2 cm, with the wound described as an improving/healing deep purple non-blanchable discoloration with a large intact blister and no open areas or skin breakdown. The most recent wound care orders directed staff to cleanse the left heel with NS, pat dry, apply skin prep, cover with ABD gauze pads, and loosely wrap with kerlix every dayshift and PRN, and the WNP also documented that the resident was to wear offloading boots. During observation, the resident was found sitting in a wheelchair with offloading boots that were not properly attached to the left heel. When the ADON removed the bandage, kerlix was wrapped around the left foot but no ABD bandage was present underneath as ordered. The ADON confirmed these observations at the time of the wound care.
Significant Medication Errors for Antihypertensive and IV Antibiotic Therapy
Penalty
Summary
The facility failed to ensure Resident #24 was free from a significant medication error related to antihypertensive treatment. Resident #24 had diagnoses including high blood pressure and multiple sclerosis, and the MDS indicated impaired cognition, dependence with toileting, bathing, and personal hygiene, and bowel and bladder incontinence. On 03/25/26, the resident complained of a headache, had abnormal vital signs, and appeared more confused than baseline; the blood pressure was documented at 200/105 and later 188/90. Hospice was contacted and ordered Losartan 50 mg daily, but the MAR showed the medication was not administered until the following morning. The ADON confirmed the resident had headache complaints and increased confusion and stated the Losartan should have been administered when the symptoms of high blood pressure were present. The facility also failed to ensure Resident #121 received ordered IV medications. Resident #121 had multiple serious diagnoses including acute and chronic respiratory failure, morbid obesity, peritoneal abscess, diverticulitis with perforation and abscess with bleeding, high blood pressure, chronic kidney disease, hypothyroidism, lymphedema, and a colostomy. Physician orders included Daptomycin 1 gram IV every 24 hours, Meropenem 1 gram IV every 8 hours, and Mycamine 100 mg IV every 24 hours for an elevated white blood cell count. Review of the MAR showed missed doses of Daptomycin on 01/30/25, 01/31/25, 02/09/25, and 02/10/25; Meropenem on 02/18/26 at 6:00 A.M.; and Mycamine on 02/09/25, 02/14/25, and 02/15/25. The nursing progress notes did not document a reason for the missed doses, and the DON stated she did not know why the resident did not receive the IV antibiotics and antifungal medication during the stay.
Unattended Medications Left at Bedside
Penalty
Summary
Medications were left unattended at the bedside of a resident who was admitted with diagnoses including diabetes, chronic pain, depression, anxiety, and hypertension. The resident’s MDS assessment indicated no cognition score because the resident was rarely understood, and the resident was dependent for toileting, bathing, and personal hygiene and was non-ambulatory. During observation, a medication cup containing two white tablets and one capsule was found on the resident’s bedside table while the resident was sleeping. An RN confirmed the cup was in the room but could not identify the medications and stated the resident had not yet received them, adding they may have been left from the evening shift. The resident was unaware the medication cup was present and could not say when the medications had been left.
Ordered HgA1C Labs Not Completed Quarterly
Penalty
Summary
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results was not ensured for one resident. Resident #29 was admitted with multiple diagnoses including encephalopathy, spastic hemiplegia, type 2 diabetes mellitus with diabetic neuropathy, dysphagia, major depressive disorder, anxiety, schizoaffective disorder, legal blindness, obstructive sleep apnea, cerebral palsy, essential hypertension, diastolic heart failure, mild intellectual disabilities, and anemia. The resident had a physician order dated 12/18/24 for HgA1C labs every 3 months in December, March, June, and September, but there was no evidence of an HgA1C for March 2026. During a Resident Council meeting, the resident stated she had been ordered quarterly labs to check her HgA1C and had not had lab work completed recently. An RN ADON confirmed the resident's A1C levels were not checked quarterly as ordered, and the medical record showed the original lab order was discontinued and reordered on 05/19/26.
Infection Control Failures During Contact Isolation Care and Wound Treatment
Penalty
Summary
Infection prevention and control standards were not followed during care for a resident with active contact isolation orders for MDRO/ESBL. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, systemic lupus, aphasia, locked-in syndrome, gastrostomy status, and ESBL resistance, and was dependent on staff for ADLs with severely impaired cognitive skills. Although the resident’s chart, care plan, and MAR reflected contact precautions, RN #416 entered the room without gown or gloves, applied gloves only after entering, hooked up the enteral feeding tube, then removed the gloves and exited without hand hygiene. The RN stated she thought the resident was only on enhanced barrier precautions for Foley care and did not know the resident was ordered contact isolation. The same resident was later observed receiving care from CNA #327 and CNA #426 without PPE. CNA #327 entered the room to answer the call light, repositioned the resident, and went into the in-room bathroom to wash hands. CNA #426 then entered without PPE, spoke with CNA #327, and adjusted the resident’s touch pad call light. During interview, both CNAs stated they believed the resident’s contact isolation had been removed and neither could identify the yellow sign on the door. LPN #335 also told staff the isolation had been discontinued, while the ADON verified the resident still had active physician’s orders for contact isolation related to MDRO. Wound care was also performed without proper infection control for a resident with an unstageable pressure ulcer to the right heel. The resident had diagnoses including difficulty walking, muscle weakness, dysphagia, and need for personal care assistance, and was dependent for toileting, bathing, personal hygiene, and transfers. During wound care, RN #350 placed supplies on the resident’s bed, used non-wound care scissors from her pocket to remove the kerlix dressing without disinfecting them, cleansed the wound, applied calcium alginate and Medihoney, covered the wound, and wrapped it with kerlix. The RN did not change gloves or perform hand hygiene after cleansing the wound and before applying the new dressing, and later confirmed these actions during interview.
Failure to Administer Consented Influenza Vaccine
Penalty
Summary
Failure to administer the influenza vaccine occurred for Resident #3 after the resident had already provided consent. Resident #3 was admitted on 12/29/25 with diagnoses including chronic obstructive pulmonary disease, morbid obesity, anxiety, and tracheostomy status. Review of the Vaccine Informed Consent Form (CRNF) - V 3 dated 12/31/25 showed that Resident #3 consented to receive the influenza vaccine. Review of the immunizations section of the electronic medical record showed no data available for Resident #3. On 06/02/26, the DON confirmed that Resident #3 had consented to receive the influenza vaccine and that the immunization section showed no documentation of administration. The DON further confirmed that Resident #3 did not receive the influenza vaccination after providing consent. The facility policy for influenza vaccine stated that residents without contraindications would be offered the influenza vaccine annually between October and March, and that the date of vaccination, lot number, person administering the vaccine, and site of vaccination would be documented in the medical record.
Failure to Protect Residents from Misappropriation of Funds and Exploitation
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property and exploitation, affecting 13 residents with resident funds accounts. The Business Office Manager (BOM) was found to have written checks to herself from resident funds, often without proper authorization or documentation from residents or their legal representatives. In several cases, the BOM purchased items that were not authorized by families or guardians, and many of these items were not found in the residents' possession. The BOM also wrote a check to her father to cash on her behalf, further violating facility policy and resident trust. Multiple interviews and record reviews revealed that the BOM bypassed established procedures for resident fund management, including the division of duties and requirements for receipts and vendor payments. Staff members reported that packages addressed to the BOM would arrive at the facility, and the BOM would direct staff on how to distribute or label the items. In some instances, staff questioned the appropriateness and cost of items purchased, such as expensive electronics and jewelry for residents with cognitive impairments, but did not escalate their concerns to administration. The BOM admitted to writing checks to herself and using her own credit card for purchases, but failed to document family authorizations or maintain proper records for many transactions. Affected residents included those with severe cognitive impairments, such as dementia, and those with legal guardians, as well as cognitively intact individuals. In several cases, families and guardians confirmed they did not authorize the purchases made on behalf of the residents, and some residents reported not receiving the items or not consenting to the expenditures. The facility's internal investigation, supported by police involvement, confirmed that misappropriation occurred, with missing receipts, unauthorized purchases, and funds withdrawn for items not received by residents.
Failure to Provide Timely Behavioral Health and Pain Management Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement a person-centered care plan to support the behavioral health care needs of a resident with multiple psychiatric and physical diagnoses, including borderline personality disorder, PTSD, generalized anxiety disorder, severe morbid obesity, and chronic pain conditions. The resident had documented care plans addressing pain management, behavioral symptoms, aggressive behaviors, and psychiatric/mood issues, with specific interventions such as timely medication administration, emotional support, and strategies to minimize behavioral triggers. Despite these plans, the resident did not receive scheduled medications at the prescribed time after requesting them during the night, resulting in a delay of care. On the night in question, the resident requested her scheduled medications at 4:00 A.M., but the assigned RN was on break. Upon returning, the RN did not attempt to administer the medications or seek assistance from other available nurses, despite the presence of additional licensed staff on duty. The RN reported feeling unsafe due to the resident's agitated and hostile behavior, which included yelling and making derogatory remarks. Instead of following up with the physician or nurse practitioner regarding the late medication request, the RN only contacted facility management via text and did not receive a timely response. The resident ultimately did not receive her medications until several hours later, after experiencing significant pain. Interviews and documentation confirmed that other nurses could have administered the medications, and that the RN's failure to do so was not in accordance with facility policy or standard nursing practice. The facility's medication administration policy required medications to be given as ordered, and the behavioral assessment policy emphasized individualized interventions to address residents' needs. The incident was substantiated by medical record review, staff interviews, and disciplinary action taken against the RN for failing to provide necessary care.
Failure to Develop Individualized PTSD Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). Despite the resident's medical record indicating diagnoses of generalized anxiety, borderline personality disorder, major depressive disorder, and PTSD, there was no assessment completed to identify the specific cause of PTSD or potential triggers that could lead to re-traumatization. The care plan only generally referenced psychiatric and mood status but did not specify PTSD triggers or interventions to minimize risk. Interviews revealed that the resident was cognitively intact and independently mobile, and had reported being bothered when people entered her personal space, which was a known trigger for her PTSD. Staff interviews indicated a lack of awareness regarding the resident's PTSD triggers, with both nursing and CNA staff stating they were unaware that proximity could cause the resident anxiety until the resident herself informed them. The Social Services Director confirmed that while a PTSD checklist was completed and triggers were discussed verbally, this information was not documented in the medical record or care plan. As a result, no formal interventions were developed or communicated to staff to address the resident's PTSD triggers, and the facility did not have a PTSD-specific policy in place.
Failure to Timely Change Soiled Bedding and Maintain Shower Room in Good Repair
Penalty
Summary
The facility failed to ensure that visibly soiled bedding was changed in a timely manner for a resident with quadriplegia, tracheostomy status, ventilator dependence, and a gastrostomy tube. Observation revealed a dried, brownish stain approximately 2.5 inches in size on the resident's sheet near the right wrist. The resident was dependent on staff for all activities of daily living and had intact cognition. A registered nurse verified the stain and believed it was blood from a small scabbed area on the resident's right arm, possibly related to a recent blood draw. The Director of Nursing confirmed that linens should be changed when visibly soiled and provided lab results indicating a blood draw had occurred the previous day. Additionally, the facility failed to maintain the south wing shower room in good repair. Observation showed a basketball-sized hole with broken tiles in the lower part of the wall between the shower and bathroom, under the hand sanitizer. A certified nursing assistant confirmed the damage but was unsure how long it had been present. This issue had the potential to affect 35 residents who used the south wing shower room.
Failure to Maintain Comfortable Room Temperatures for Residents
Penalty
Summary
The facility failed to maintain comfortable room temperatures for two residents, both of whom had significant medical conditions including respiratory failure and tracheostomy status. For one resident, observations revealed that the air conditioning unit in the room was turned off, leaking, and not functioning properly, with wet blankets placed underneath and a fan provided as a temporary measure. The front of the air conditioning unit was removed and lying beside the wall, and maintenance staff were unaware of the malfunction until it was brought to their attention. Nursing staff confirmed the room was hot and the resident was sweating, and the family had reported concerns about the room temperature over the weekend. Documentation showed that the last recorded room temperature was several days prior, and a grievance had been filed by the family regarding the environmental conditions. For the second resident, similar issues were observed with the air conditioning unit, which was only slightly blowing cold air and required the use of two fans in the room. The ambient temperature in the room was measured at 81.4 degrees Fahrenheit. The resident's family also reported that the room was hot and the air conditioning was not working properly. Facility policy required maintaining a comfortable and safe temperature for residents, but observations and interviews indicated that this was not achieved for these two residents.
Failure to Comprehensively Monitor Resident's Bruising
Penalty
Summary
The facility failed to comprehensively assess and monitor scattered bruises on Resident #200, which were discovered following a fall. The resident, who had a history of cerebral infarction, muscle weakness, and aphasia, was admitted to the facility and later discharged against medical advice. Upon admission, the resident did not have any skin impairments, but after a fall on the premises, bruising was noted on the resident's arms, legs, and face. Although there were orders to monitor the bruising every shift, the documentation lacked detailed descriptions, measurements, and progression of the bruises. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, confirmed that the bruising was documented as scattered bruises in the initial fall report. However, the medical record did not provide evidence of comprehensive assessments and monitoring of the bruising. The resident's wife was informed of the bruising, and staff were monitoring it, but the lack of detailed documentation was noted as a deficiency during the complaint investigation.
Unauthorized Disclosure of Resident's Medical Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's medical records. Resident #3, who had severe cognitive impairment and was admitted with diagnoses including malignant neoplasm of the lung and cognitive communication deficit, had her medical information improperly disclosed. The resident's powers of attorney (POA) were the only non-providers authorized to access her medical information. However, the facility mistakenly gave the resident's medical records to her sister, who was not authorized to access them, due to a miscommunication during a care conference. The Licensed Social Worker (LSW) left the records at the front desk for pickup, not realizing the requesting family member was unauthorized. The incident was confirmed through interviews with the POA, the LSW, the unauthorized family member, and the facility administrator. The facility's medical information policy, which mandates the privacy of residents' health information, was reviewed and found to have been violated. This deficiency was identified during a complaint investigation and affected one resident out of a facility census of 125.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure alleged abuse events were reported and investigated appropriately, affecting one resident of five reviewed for abuse prohibition. Resident #19, who had severe cognitive impairment and other diagnoses, called the police on 02/06/24, claiming staff beat her and treated her harshly. The police found no concerns regarding resident safety and left the facility. However, there was no documentation of any related skin assessment, notification to management, or investigation into the allegation. Interviews with the resident and LPN confirmed the incident, but the LPN could not recall notifying management, and no report or investigation was submitted to the Ohio Department of Health Certification and Licensure website. The facility's abuse prevention policy, dated 09/2021, required allegations of abuse to be promptly investigated and reported to relevant government agencies. The Administrator confirmed the findings during an interview. This deficiency represents noncompliance investigated under Master Complaint Number OH00152273 and Complaint Number OH00151735.
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What surveyors actually found near you
We read the 1,047 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Broadview Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaks Of Brecksville | 1.5 mi | ★★★★★ | 0 | 0 |
| Avenue At Broadview Heights | 1.9 mi | ★★★★★ | 14 | 0 |
| Regina Health Center | 3.4 mi | ★★★★★ | 2 | 0 |
| Brentwood Health Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Momentous Health At Richfield | 4.3 mi | — | 21 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.